Basic Information
| Provider Information | |||||||||
| NPI: | 1700010501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRO DE MEDICINA CARDIOVASCULAR Y MEDICINA NUCLEAR SAN CARLOS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 976 | ||||||||
| Address2: | |||||||||
| City: | QUEBRADILLAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878778000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | CONCEPCION VERA AYALA 550 HOSPITAL SAN CARLOS BORROMEO | ||||||||
| Address2: | 1ER PISO | ||||||||
| City: | MOCA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878778000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 07/22/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LA SALLE | ||||||||
| AuthorizedOfficialFirstName: | CONFESOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | STOCKHOLDER | ||||||||
| AuthorizedOfficialTelephone: | 7874399462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.